PMS (Premenstrual Syndrome) and PMDD (Premenstrual Dysphoric Disorder) usually present with both physical and mood symptoms. PMS and PMDD affect approximately 20-30% of menstruating women. The average age at which women seek treatment is in the early 30’s. There is not a set criteria for diagnosis of PMS. However, the more severe version of PMS referred to as PMDD does have a set criteria for diagnosis. Recent population-based studies have found no association between PMS and any demographic or personal habits such as education, income, employment status, or marital status. There is a higher rate of PMS/PMDD in Hispanic women and a lower rate among Asian women compared to Caucasian females.
Emotional symptoms are the most common reason that women seek treatment, with irritability being by far the most common symptom. Other emotional symptoms include depression, anxiety, sadness, crying spells, anger, and mood lability. The most common physical symptoms are breast tenderness, fatigue, insomnia, abdominal bloating, weight gain, appetite increase, hot flashes, headache, and muscle/joint aches.
PMS is diagnosed when women report at least one of the symptoms listed above during the five days before menses in each of the three prior menstrual cycles. The symptoms are relieved within 3-4 days of the onset of menses without recurrence until the middle of the next cycle. The symptoms cause dysfunction in some aspect of the patient’s life — personal, work, social, etc.
PMDD is diagnosed when most menstrual cycles during the past year have 5 or more of the following symptoms:
1. Markedly depressed moods or feeling of hopelessness
2. Marked anxiety or tension
3. Marked mood swings
4. Persistent anger or irritability
5. Loss of interest in past enjoyable activities
6. Difficulty concentrating
7. Lethargy and fatigue
8. Marked change in appetite
9. Change in sleep, insomnia, or hypersomnia
10. Sense of being overwhelmed or out of control
11. Other physical symptoms: breast tenderness, abdominal bloating, headache, swelling of extremities, muscle/joint aches
Symptoms start 4 days prior to menses and end 4-5 days after start of menses. The disturbance interferes with some aspects of the patient’s life. The problem is not related to other underlying problems such as depression or anxiety.
Treatment for PMS/PMDD has improved significantly in the last few years. The serotonergic antidepressants (SSRIs) such as Prozac, Zoloft, and Paxil have been proven to be extremely effective in treating the majority of symptoms. The SSRIs improve both mood and physical symptoms as well as the patient’s overall functioning, including work productivity and social relationships. They work rapidly with significant improvement seen within the first cycle of treatment. They can be used on a continuous basis or intermittently during the premenstrual period. Intermittent dosing offers advantages with lower costs and possible reduction in some side effects such as weight gain and decreased sex drive. The major disadvantage is with intermittent dosing is that women have to track their start and stop dates. Other treatments that have demonstrated some usefulness with PMS/PMDD are exercise on a regular basis and calcium 600mg twice daily. Chaste berry (vitex agnus castus) is an herbal treatment that has shown some promise for treatment of PMS/PMDD. Further study of this herbal treatment is ongoing.
Mark Smith, M.D.